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5 Hospital OQR Program Calendar Year (CY) 2018 Chart-Abstracted Validation Overview for Selected Hospitals Alex Feilmeier Lead Health Informatics Solutions Coordinator Value, Incentives, and Quality Reporting Center (VIQRC) Validation Support Contractor (VSC) February 15, 2017

6 Purpose The purpose of this session is to educate and share information regarding the Centers for Medicare & Medicaid Services (CMS) Hospital Outpatient Quality Reporting (OQR) Program Chart-Abstracted Data Validation process for CY /15/2017 6

7 Objectives Participants will be able to: Understand the CY 2018 Hospital OQR Chart- Abstracted Data Validation Program process, as a whole. Identify the deadlines and associated required activities relating to data validation for CY Submit medical records requested by the CMS Clinical Data Abstraction Center (CDAC). Receive and interpret validation results. 2/15/2017 7

8 Background CMS assesses the accuracy of chart-abstracted data submitted to the OQR Program through the validation process. CMS verifies on a quarterly basis that hospitalabstracted data submitted to the clinical warehouse can be reproduced by a trained abstractor using a standardized protocol. CMS performs a random and targeted selection of Outpatient Prospective Payment Systems (OPPS) hospitals on an annual basis. The random and targeted selection for CY 2018 occurred in August of The selection includes up to 500 hospitals including 450 randomly selected hospitals and up to 50 targeted hospitals. It is possible for a hospital to be selected in consecutive years. 2/15/2017 8

9 Validation Quarters for CY 2018 Validation Quarters for CY 2018 First quarter 2016 (1Q16) Second quarter 2016 (2Q16) Third quarter 2016 (3Q16) Fourth quarter 2016 (4Q16) 2/15/2017 9

10 Measures for CY 2018 CMS will validate up to 12 cases for clinical process of care measures per quarter, per hospital. Cases are randomly selected from data submitted to the clinical warehouse by the hospital. Below is a list of the measures available to be validated in CY OP-1: Median Time to Fibrinolysis Measures Validated in CY 2018 OP-2: Fibrinolytic Therapy Received Within 30 Minutes of ED Arrival OP-3: Median Time to Transfer to Another Facility for Acute Coronary Intervention OP-4: Aspirin at Arrival OP-5: Median Time to ECG OP-18: Median Time from ED Arrival to ED Departure for Discharged ED Patients OP-20: Door to Diagnostic Evaluation by a Qualified Medical Professional OP-21: Median Time to Pain Management for Long Bone Fracture OP-23: Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke who Received Head CT or MRI Scan Interpretation Within 45 minutes of ED Arrival 2/15/

11 Selected Provider List The list of selected providers is posted on QualityNet on the Hospitals - Outpatient > Data Validation page. The list is located on the upper-right side of the screen within a box titled, Hospitals Selected for Outpatient Data Validation. 2/15/

12 Notification of Selection (1 of 2) Annually, for both the random and targeted provider selections: A news article, along with the list of selected providers, is posted on QualityNet. A ListServe is released to notify the community that the selection has occurred. An communication from the VSC is sent directly to the hospitals selected. 2/15/

13 Notification of Selection (2 of 2) Hospitals selected for OQR validation are notified by communication. This communication is sent to the following hospital contact types listed within the official CMS contact database: o CEO o Hospital OQR o Medical Records o Quality Improvement The VSC monitors communications sent to assure that all hospitals are notified of selection. Any bounce backs are researched, and hospital contacts updated in the CMS system, to assure that future notifications are received. 2/15/

14 Updating and Keeping Contacts Up-to-Date Keeping hospital contacts up-to-date is necessary to ensure validation-related communications and submission deadline reminders reach appropriate staff at your hospital. Hospitals may check who is listed and make updates to their contacts by filling out the Hospital Contact Change Form (direct link below) and the completed form to the Direct link for form: content/uploads/2017/01/hospital-contact-correction- FormFF pdf 2/15/

15 General Overview of Validation Process (Part 1 of 3) Quarterly, cases are randomly selected from data submitted to the clinical warehouse by the hospital. After the cases for validation have been selected for the quarter, the hospital receives a medical records request packet from the CDAC. The CDAC will mail a medical records request packet to the attention of Medical Records Director, which contains detailed instructions and case listings. o It typically takes ten or more days after the quarter s submission deadline for this sample of cases to be selected and sent out. The hospital has until the date listed on the quarter s request to send their records to the CDAC. Quarterly, the hospital delivers requested medical records to the CDAC, and the CDAC then re-abstracts and adjudicates the selected cases. 2/15/

16 General Overview of Validation Process (Part 2 of 3) It typically takes approximately four months after the quarter s submission deadline for hospitals to receive their validation results for the quarter. o An is sent to the QualityNet Security Administrator that results are available. It is strongly recommended that each hospital have at least two active Security Administrators at all times. If you are unable to log in to the QualityNet Secure Portal, contact your hospital QualityNet Security Administrator. If your Security Administrator is unable to reestablish your access, contact the QualityNet Help Desk at (866) Hospitals may submit an educational review request within 30 days of receiving quarterly results. o The educational review process and educational review forms can be found on the Hospitals - Outpatient > Data Validation Educational Reviews page of QualityNet. 2/15/

17 General Overview of Validation Process (Part 3 of 3) At the end of each calendar year, annual payment update (APU) results are expected to be released in the fall (for calendar year 2018, this is anticipated to be October 2017), at which point hospitals will be notified of their validation pass-fail status. The determination of a pass or fail status involves CMS calculating a total score for all quarters. Hospitals may run their end-of-year Confidence Interval Report, which determines validation pass or fail status. If the upper bound of the confidence interval is 75 percent or higher, the hospital will pass the Hospital OQR Program validation requirement. 2/15/

18 CY 2018 Validation Deadlines Encounter Quarters Validation Due Dates Clinical Data Submission Deadline Scheduled CDAC Record Requests (approximate) 1Q16 (January 1 March 31) 08/01/2016 September Q16 (April 1 June 30) 11/01/2016 December Q16 (July 1 September 30) 02/01/2017 March Q16 (October 1 December 31) 05/01/2017 June /15/

19 Medical Record Request (Part 1 of 4) CDAC will send hospitals a written request to Medical Records Director, using FedEx, to submit a patient medical record for each case that CMS selected for validation. It is important that the packet be routed to the correct individual(s) responsible for fulfilling the request as soon as possible. IMPORTANT NOTE: The medical records request will be delivered to the address listed under the MEDICAL RECORDS contact type in the official CMS database. Hospitals may check the address and make updates to the address by sending an with their six-digit CCN/Provider ID to QRSupport@hcqis.org. 2/15/

20 Medical Record Request (Part 2 of 4) A hospital s list of cases selected for validation each quarter, including all available patient identifiers, can be accessed via the QualityNet Secure Portal by a registered user with the appropriate reports role. Please note that this report can take several business days after original request date to become available. To access the report: 1. Log in to the QualityNet Secure Portal 2. Select My Reports followed by Run Reports 3. Select OQR Program: Hospital Reporting Data Validation Reports 4. Select Hospital Data Validation Case Selection Report 2/15/

21 Medical Record Request (Part 3 of 4) Hospitals are not allowed to send records or additional documentation after the record has been received by the CDAC; this applies even if the wrong record is sent, or if pages are missing, or illegible, etc. The CDAC will abstract every case with the applicable documentation that the hospital originally sent. It is critical that hospitals have a process for reviewing each of their records after they have been copied and prior to being sent to the CDAC. All records should be carefully reviewed prior to mailing them to the CDAC. o Consider having an abstractor review your records prior to mailing as they are most familiar with the location of the information needed for abstraction. o This is especially important if printing records from an Electronic Health Record (EHR) to ensure all necessary information is present. 2/15/

22 Medical Record Request (Part 4 of 4) Hospitals have until the date listed on the request to send their records to the CDAC. o OQR records must be received within 45 days of the request date. Hospitals may submit medical records on paper copy, removable media (CD/DVD/flash drive), or via the QualityNet Secure Portal Secure File Transfer Application. Detailed instructions on how to submit medical records via any of those three methods are provided within the packet delivered by CDAC. Additional information about the request for medical records can be found on QualityNet: o Select Data Validation from the Hospitals - Outpatient tab drop-down. o Select CDAC Information from the left-side navigation pane (direct link): Public%2FPage%2FQnetTier3&cid= /15/

23 Quarterly Validation Reports Case Selection Report o Displays the patient-identifying information pertaining to the cases selected for validation. The cases on this report are the same cases as outlined within the medical records request packet sent by CDAC. Validation Summary o Provides a high-level summary of the validation-reliability rate for each abstracted case. Becomes available after hospital receives results for the quarter. Validation Case Detail o Provides a list of all elements abstracted compared to the CDAC reabstraction on each case. Becomes available after hospital receives results for the quarter. 2/15/

24 Case Selection Report Lists hospital s cases selected for validation each quarter, including all available patient identifiers. Displays the Medical Record Request Date, the Due to CDAC Date, and the Record Received Date (after CDAC has received hospital s records). Please note, it could take up to 24 hours for the Record Received Date to populate. To verify receipt of records, contact the CDAC directly via at CDACHelpDesk@hcqis.org, or by phone at (717) , ext /15/

25 Validation Summary Report Lists each validated case with its score, organized by measure set. 2/15/

26 Case Detail Report Lists all abstracted elements compared to the CDAC reabstraction on each case. Mismatches and the associated educational comments from CDAC are displayed in red font. 2/15/

27 Educational Reviews Within 30 days of validation results being posted on the My Reports section of the QualityNet Secure Portal, if a hospital has a question or needs further clarification on a particular outcome, the hospital may request an educational review. NOTE: Quarterly validation results will not be changed as a result of this review; however, CMS suggests hospitals will use the opportunity to receive education and guidance for future submissions. The information needed to request a review can be found on QualityNet: o Select Data Validation from the Hospitals - Outpatient tab drop-down. o Select Educational Reviews from the left-side navigation pane (direct link): %2FQnetTier3&cid= /15/

28 Confidence Interval Report After all quarterly results of the calendar year have been completed, a confidence interval is calculated based on the cumulative results. To pass validation, a hospital must receive equal to, or greater than, a 75 percent upper bound confidence interval score. o If a hospital does not meet the overall validation requirement, the hospital will not receive full APU. 2/15/

29 Reconsiderations If a hospital does not meet the overall validation requirement during APU, the hospital receives a letter in the fall indicating they have failed APU. o At that time, a hospital may request a reconsideration (appeal) of their validation results. The hospital would then provide information on why they are asking CMS to reconsider their results. Additional information about reconsiderations can be found on QualityNet: o Select Hospital Outpatient Quality Reporting Program from the Hospitals - Outpatient tab drop-down. o Select APU Reconsideration from the left-side navigation pane (direct link): ublic%2fpage%2fqnettier3&cid= /15/

30 Resources Validation resources are available on QualityNet. To access these resources: o Select the Data Validation link from the Hospitals - Outpatient tab drop-down. o Select the Resources link from the left side navigation pane (direct link): e=qnetpublic%2fpage%2fqnettier3&cid= For assistance with QualityNet, including logging in, contact the QualityNet Help Desk: o By telephone, 7 a.m. 7 p.m. CT, Monday Friday at (866) 288- o 8912 By at qnetsupport@hcqis.org 2/15/

31 Questions CMS Hospital Outpatient Questions and Answers tool o Validation Support Contractor o validation@hcqis.org When submitting a question, include the hospital six-digit CCN/Provider ID o Expedites a reply with information specific to your hospital 2/15/